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Ageno W, Bertù L, Bucherini E, Camporese G, Dentali F, Iotti M, Lessiani G, Parisi R, Prandoni P, Sartori M, Visonà A, Bigagli E, Palareti G. Rivaroxaban treatment for six weeks versus three months in patients with symptomatic isolated distal deep vein thrombosis: randomised controlled trial. BMJ 2022; 379:e072623. [PMID: 36520715 PMCID: PMC9682494 DOI: 10.1136/bmj-2022-072623] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare two different treatment durations of rivaroxaban in patients with symptomatic isolated distal deep vein thrombosis (DVT). DESIGN Randomised, double blind, placebo controlled clinical trial. SETTING 28 outpatient clinics specialising in venous thromboembolism. PARTICIPANTS 402 adults (≥18 years) with symptomatic isolated distal DVT. INTERVENTIONS After receiving standard dose rivaroxaban for six weeks, participants were randomly assigned to receive rivaroxaban 20 mg or placebo once daily for an additional six weeks. Follow-up was for 24 months from study inclusion. MAIN OUTCOMES MEASURES The primary efficacy outcome was recurrent venous thromboembolism during follow-up after randomisation, defined as the composite of progression of isolated distal DVT, recurrent isolated distal DVT, proximal DVT, symptomatic pulmonary embolism, or fatal pulmonary embolism. The primary safety outcome was major bleeding after randomisation until two days from the last dose of rivaroxaban or placebo. An independent committee adjudicated the outcomes. RESULTS 200 adults were randomised to receive additional rivaroxaban treatment and 202 to receive placebo. Isolated distal DVT was unprovoked in 81 (40%) and 86 (43%) patients, respectively. The primary efficacy outcome occurred in 23 (11%) patients in the rivaroxaban arm and 39 (19%) in the placebo arm (relative risk 0.59, 95% confidence interval 0.36 to 0.95; P=0.03, number needed to treat 13, 95% confidence interval 7 to 126). Recurrent isolated distal DVT occurred in 16 (8%) patients in the rivaroxaban arm and 31 (15%) in the placebo arm (P=0.02). Proximal DVT or pulmonary embolism occurred in seven (3%) patients in the rivaroxaban arm and eight (4%) in the placebo arm (P=0.80). No major bleeding events occurred. CONCLUSIONS Rivaroxaban administered for six additional weeks in patients with isolated distal DVT who had an uneventful six week treatment course reduces the risk of recurrent venous thromboembolism, mainly recurrent isolated distal DVT, over a two year follow-up without increasing the risk of haemorrhage. TRIAL REGISTRATION EudraCT 2016-000958-36; ClinicalTrials.gov NCT02722447.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Lorenza Bertù
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | | | - Giuseppe Camporese
- Unit of Angiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Matteo Iotti
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Gianfranco Lessiani
- Angiology Unit, Department of Internal Medicine, Villa Serena Hospital, Città Sant'Angelo, Italy
| | - Roberto Parisi
- Department of Medicine, SS Giovanni e Paolo Hospital, Venice, Italy
| | | | - Michelangelo Sartori
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Adriana Visonà
- Angiology Unit, Azienda ULSS 2 Marca Trevigiana, Castelfranco Veneto, Italy
| | - Elisabetta Bigagli
- Department of Neuroscience, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
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Albricker ACL, Freire CMV, Santos SND, Alcantara MLD, Saleh MH, Cantisano AL, Teodoro JAR, Porto CLL, Amaral SID, Veloso OCG, Petisco ACGP, Barros FS, Barros MVLD, Souza AJD, Sobreira ML, Miranda RBD, Moraes DD, Verrastro CGY, Mançano AD, Lima RDSL, Muglia VF, Matushita CS, Lopes RW, Coutinho AMN, Pianta DB, Santos AASMDD, Naves BDL, Vieira MLC, Rochitte CE. Diretriz Conjunta sobre Tromboembolismo Venoso – 2022. Arq Bras Cardiol 2022; 118:797-857. [PMID: 35508060 PMCID: PMC9007000 DOI: 10.36660/abc.20220213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Outcomes of isolated distal thrombosis managed with serial compression ultrasonography. Thromb Res 2021; 208:66-70. [PMID: 34717132 DOI: 10.1016/j.thromres.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/27/2021] [Accepted: 10/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Isolated distal deep vein thrombosis (IDDVT) is a common subtype of deep vein thrombosis (DVT). Consensus guidelines provide conflicting recommendations for IDDVT management; some recommend anticoagulant treatment, while others suggest serial compression ultrasonography (CUS) monitoring for patients not at "high risk" of proximal extension. The purpose of this study was to describe outcomes of serial CUS-monitored IDDVT and identify risk factors for proximal thrombus extension or anticoagulant treatment initiation. METHODS A retrospective descriptive study was conducted using electronic data from University of Utah Health. Adult subjects with objectively confirmed, serial CUS-monitored IDDVT were included. Subjects were followed for 30 days for occurrence of a composite outcome of proximal thrombus extension or anticoagulant treatment initiation. Descriptive statistics were used to summarize characteristics of the study population. Characteristics were compared across outcome groups using inferential statistics. RESULTS A total of 182 subjects were included, with 53 subjects (29.1%) experiencing the composite outcome. Of these, 12 (22.6%) experienced proximal thrombus extension and 41 (77.4%) initiated anticoagulant treatment. A prior history of venous thromboembolism (VTE) was significantly higher in those who experienced the composite outcome than in those who did not. CONCLUSIONS Our results suggest that 70% of patients with serial CUS-monitored IDDVT did not experience thrombus extension or require anticoagulant treatment within 30 days of diagnosis, regardless of risk factors for proximal extension. Serial CUS monitoring may be a useful management strategy for IDDVT. A history of VTE may identify patients more likely to experience proximal thrombus extension or require anticoagulation.
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Makedonov I, Galanaud JP, Kahn SR. Significance and management of isolated distal deep vein thrombosis. Curr Opin Hematol 2021; 28:331-338. [PMID: 34267078 DOI: 10.1097/moh.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Management of isolated distal deep vein thrombosis (IDDVT) remains controversial. We summarize recent studies regarding the natural history of IDDVT as well as pertinent therapeutic trials. We also provide our management approach. RECENT FINDINGS IDDVT is more commonly associated with transient risk factors and less often associated with permanent, unmodifiable risk factors than proximal DVT. IDDVT has a significantly lower risk of proximal extension and recurrence than proximal DVT. Cancer-associated IDDVT has a similar natural history to cancer-associated proximal DVT, with substantially less favourable outcomes than noncancer-associated IDDVT. Anticoagulant treatment reduces the risk of proximal extension and recurrence in IDDVT at the cost of increased bleeding risk. Intermediate dosing of anticoagulation may be effective for treating noncancer-associated IDDVT in patients without prior DVT. SUMMARY IDDVT with a transient risk factor can be treated for 6 weeks in patients without a prior DVT. Unprovoked IDDVT in patients without malignancy can be treated for 3 months. Outpatients without malignancy or a prior DVT can be left untreated and undergo surveillance compression ultrasound in one week to detect proximal extension, but few patients opt for this in practice. Cancer-associated IDDVT should be treated analogously to cancer-associated proximal DVT.
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Affiliation(s)
- Ilia Makedonov
- Department of Medicine, Division of General Internal Medicine, Sunnybrook Health Sciences Center
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - Susan R Kahn
- Center for Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute; Division of Internal Medicine, Department of Medicine, McGill University, Montreal, Québec, Canada
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Kuczmik W, Wysokinski WE, Macedo T, Froehling D, Daniels P, Casanegra A, Houghton D, Vlazny D, Meverden R, Lang T, White L, Hodge D, McBane RD. Calf Vein Thrombosis Outcomes Comparing Anticoagulation and Serial Ultrasound Imaging Management Strategies. Mayo Clin Proc 2021; 96:1184-1192. [PMID: 33840522 DOI: 10.1016/j.mayocp.2021.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/09/2020] [Accepted: 01/06/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare outcomes among patients with calf deep vein thrombosis (DVT) stratified by management strategy because distal or calf DVT is said to have low rates of propagation, embolization, and recurrence and, as such, guideline recommendations include provisions for serial imaging without treatment. PATIENTS AND METHODS Consecutive patients with ultrasound-confirmed acute DVT involving the calf veins (January 1, 2016, to August 1, 2018) were identified by scrutinizing the Gonda Vascular Center Ultrasound database. Patients were segregated into 2 categories depending on management strategy; anticoagulation vs serial surveillance ultrasound without anticoagulation. Outcomes including venous thromboembolism (VTE) recurrence, bleeding, death, and net clinical benefit were compared by treatment strategy. RESULTS There were 483 patients with calf DVT identified; 399 were treated with anticoagulation therapy and 84 were managed with surveillance ultrasound. Patients in the surveillance group were older (70.0±13.9 vs 63.0±14.9 years; P<.001) and more likely to have had a recent hospitalization (76.2% [64/84] vs 45.4% [181/399]; P<.001). Common reasons for choosing ultrasound surveillance included guideline prescriptive (58.3% [49/84]), active bleeding (21.4% [18/84]), and recent surgery (17.9% [15/84]). The VTE recurrence composite was lower for patients treated with anticoagulants (7.3% [29/399]) compared with surveillance (14.3% [12/84]; P=.04). The DVT propagation was less frequent in the treated group (2.8% [11/399] vs 8.3% [7/84]; P=.01). There was no difference in bleeding or mortality outcomes by management strategy. Net clinical benefit (VTE recurrence plus major bleeding) favored anticoagulant therapy (9.8% [39/399] vs 20.2% [17/84]; P<.01). CONCLUSION Patients with calf DVT treated with anticoagulants had significantly better outcomes compared with those managed by a strategy of serial ultrasound surveillance without increasing bleeding outcomes.
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Affiliation(s)
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Thanila Macedo
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Radiology, Mayo Clinic, Rochester, MN
| | - David Froehling
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Paul Daniels
- Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Ana Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Damon Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | | | - Ryan Meverden
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Teresa Lang
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Launia White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - David Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN.
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Li Y, Ding J, Shen L, Yang J, Wang H, Zhou Y, Jiang G, Zhu Y, Wang Y. Risk Factors and Anticoagulation Therapy in Patients With Isolated Distal Deep Vein Thrombosis in the Early Post-operative Period After Thoracic Surgery. Front Surg 2021; 8:671165. [PMID: 33996889 PMCID: PMC8113622 DOI: 10.3389/fsurg.2021.671165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/01/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Isolated distal deep vein thrombosis (IDDVT) accounts for ~50% of all patients diagnosed with deep venous thrombosis (DVT), but the diagnosis and optimal management of IDDVT remains unclear and controversial. The aim of this study was to explore potential risk factors and predictors of IDDVT, and to evaluate different strategies of anticoagulation therapy. Methods: A total of 310 consecutive patients after thoracic surgery, who underwent whole-leg ultrasonography as well as routine measurements of D-dimer levels before and after surgery were evaluated. The general clinical data, anticoagulant therapy, pre- and postoperative D-dimer levels were collected. Differences between IDDVT, DVT and non-DVT groups were calculated. Logistic regression analysis was used to analyze risk factors of postoperative IDDVT. Results: Age and postoperative D-dimer levels were significantly higher in IDDVT group than in non DVT group (p = 0.0053 and p < 0.001, respectively). Logistic regression analysis showed that postoperative D-dimer level was a significant independent predictor of IDDVT even when adjusted for age and operation method (p = 0.0003). There were no significant side effects associated with both full-dose and half-dose anticoagulation regimens. Half-dose therapy was associated with a significant decrease in the requirement for anticoagulation medications after discharge (p = 0.0002). Conclusion: Age and D-dimer levels after surgery are strong predictors of IDDVT following thoracic surgery. Half-dose therapeutic anticoagulation has the same efficiency in preventing IDDVT progression, is not associated with any additional risks of adverse effects compared to a full-dose regimen, and may be adopted for treating IDDVT patients after thoracic surgery.
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Affiliation(s)
- Yuping Li
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Junrong Ding
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lei Shen
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Yang
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Haifeng Wang
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yiming Zhou
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Gening Jiang
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuming Zhu
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yin Wang
- Department of Ultrasound, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 261] [Impact Index Per Article: 65.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Elmi G, Aluigi L, Allegri D, Rinaldi ER, Camaggi V, Di Giulio R, Martignani A, Bacchi Reggiani ML, Domanico A, Antignani PL. Calf deep vein thrombosis: frequency, therapeutic management, early outcomes and all-causes mortality in a cohort of hospitalized patients. INT ANGIOL 2020; 39:467-476. [PMID: 33215909 DOI: 10.23736/s0392-9590.20.04528-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Isolated distal deep vein thromboses (IDDVT) are frequent; however, their optimal management is still controversial. METHODS We performed a retrospective study on inpatients undergoing ultrasound for suspected deep vein thrombosis (DVT) or with a particular risk profile, during 2016. This study aimed to assess the frequency of proximal deep vein thromboses (PDVT) and IDDVT; to evaluate therapeutic management and identify variables associated with early outcomes and mortality among IDDVT patients; to compare all-causes mortality between subjects with PDVT and IDDVT. RESULTS Among 21594 patients hospitalized in the study period 251 IDDVT and 149 PDVT were diagnosed; the frequency was 1.2% and 0.7% respectively. 19% of IDDVT patients died compared to 25.5% of PDVT subjects (OR=0.72; 95% CI=0.44-1.17; P=0.19). In IDDVT patients, age ≥80, cancer and intracranial bleeding increased the risk of death (OR=2; 95% CI=1.07-3.75, P=0.001; OR=8.47; 95% CI=3.28-21.88, P=0.0000003; OR=2.33; 95% CI=1.18-4.58, P=0.0003). A significant association between intracranial hemorrhage and both proximal extension by using the Fisher's exact test (P=0.031; OR=16.11; 95% CI=0.80-321.2), and composite of propagation to popliteal or to other calf veins (OR=8.28, 95% CI=2.07-33 P=0.001) was observed. Standard anticoagulation significantly reduced the composite of propagation to popliteal or to other calf veins (OR=0.07; 95% CI=0.009-0.61, P=0.007), and all-causes mortality (OR=0.37; 95% CI=0.17-0.8; P=0.02), without a significant increase of bleeding. CONCLUSIONS Among inpatients, IDDVT exceeded 60% of DVT. Mortality was not significantly different between IDDVT and PDVT subjects. Intracranial bleeding significantly increased the risk of propagation and death. Although standard anticoagulation decreased both these complications, further targeted studies are needed.
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Affiliation(s)
- Giovanna Elmi
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy -
| | | | - Davide Allegri
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Italy
| | - Elisa R Rinaldi
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Valeria Camaggi
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Rosella Di Giulio
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Alberto Martignani
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Maria L Bacchi Reggiani
- Department of Specialistic, Diagnostic and Experimental Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Andrea Domanico
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
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Elmi G, Rinaldi ER, Domanico A, Aluigi L. Calf deep vein thrombosis – clinical relevance, diagnostic approaches and therapeutic options. VASA 2020; 49:359-366. [DOI: 10.1024/0301-1526/a000869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Summary. Isolated distal deep vein thromboses (IDDVT) represent up to 50 % of legs deep vein thromboses (DVT). However, since their natural history is to date unknown, the need to diagnose and treat them is a matter of debate. The diagnostic strategy based on the assessment of pre-test probability and D-dimer demonstrated a scarse efficiency for IDDVT. The choice between a proximal and a complete ultrasonographic approach should be guided by the clinical context, the local expertise and the patient characteristics. Randomized and observational studies have analyzed the need of therapy and compared different regimens of anticoagulation, with conflicting results. Systematic reviews and meta-analyses tend to support the usefulness of an anticoagulant treatment, even if the optimal dose and duration are not still defined. A careful stratification of the patient’s profile, taking into account risk factors for proximal extension, recurrence and bleeding should address the therapeutic approach, which must always be discussed with an adequately informed patient. Further studies aimed to clarify the natural history of IDDVT, and to assess safety and efficacy of lower intensity and shorter duration protocols are urgently needed.
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Affiliation(s)
- Giovanna Elmi
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
| | - Elisa Rebecca Rinaldi
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
| | - Andrea Domanico
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
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Papakonstantinou PE, Tsioufis C, Konstantinidis D, Iliakis P, Leontsinis I, Tousoulis D. Anticoagulation in Deep Venous Thrombosis: Current Trends in the Era of Non- Vitamin K Antagonists Oral Anticoagulants. Curr Pharm Des 2020; 26:2692-2702. [DOI: 10.2174/1381612826666200420150517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/13/2020] [Indexed: 12/20/2022]
Abstract
:
Anticoagulation therapy is the cornerstone of treatment in acute vein thrombosis (DVT) and it aims to
reduce symptoms, thrombus extension, DVT recurrences, and mortality. The treatment for DVT depends on its
anatomical extent, among other factors. Anticoagulation therapy for proximal DVT is clearly recommended (at
least for 3 months), while AT for isolated distal DVT should be considered, especially in the presence of high
thromboembolic risk factors. The optimal anticoagulant and duration of therapy are determined by the clinical
assessment, taking into account the thromboembolic and bleeding risk in each patient in a case-by-case decision
making. Non-Vitamin K antagonists oral anticoagulants (NOACs) were a revolution in the anticoagulation management
of DVT. Nowadays, NOACs are considered as first-line therapy in the anticoagulation therapy for DVT
and are recommended as the preferred anticoagulant agents by most scientific societies. NOACs offer a simple
route of administration (oral agents), a rapid onset-offset of their action along with a good efficacy and safety
profile in comparison with Vitamin K Antagonists (VKAs). However, there are issues about their efficacy and
safety profile in specific populations with high thromboembolic and bleeding risks, such as renal failure patients,
active-cancer patients, and pregnant women, in which VKAs and heparins were the standard care of treatment.
Since the available data are promising for the use of NOACs in end-stage chronic kidney disease and cancer
patients, several ongoing randomized trials are currently trying to solve that issues and give evidence about the
safety and efficacy of NOACs in these populations.
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Affiliation(s)
- Panteleimon E. Papakonstantinou
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitris Konstantinidis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Panagiotis Iliakis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Ioannis Leontsinis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
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Abstract
BACKGROUND The treatment of distal (below the knee) deep vein thrombosis (DVT) is not clearly established. Distal DVT can either be treated with anticoagulation, or monitored with close follow-up to detect progression to the proximal veins (above the knee), which requires anticoagulation. Proponents of this monitoring strategy base their decision to withhold anticoagulation on the fact that progression is rare and most people can be spared from potential bleeding and other adverse effects of anticoagulation. OBJECTIVES To assess the effects of different treatment interventions for people with distal (below the knee) deep vein thrombosis (DVT). SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 12 February 2019. We also undertook reference checking to identify additional studies. SELECTION CRITERIA Randomised controlled trials (RCTs) for the treatment of distal DVT. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials and extracted data. We resolved disagreements by discussion. Primary outcomes of interest were recurrence of venous thromboembolism (VTE), DVT and major bleeding and follow up ranged from three months to two years. We performed fixed-effect model meta-analyses with risk ratio (RRs) and 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE. MAIN RESULTS We identified eight RCTs reporting on 1239 participants. Five trials randomised participants to anticoagulation for up to three months versus no anticoagulation. Three trials compared anticoagulation treatment for different time periods. Anticoagulant compared to no intervention or placebo for distal DVT treatment Anticoagulation with a vitamin K antagonist (VKA) reduced the risk of recurrent VTE during follow-up compared with participants receiving no anticoagulation (RR 0.34, 95% CI 0.15 to 0.77; 5 studies, 496 participants; I2 = 3%; high-certainty evidence), and reduced the risk of recurrence of DVT (RR 0.25, 95% CI 0.10 to 0.67; 5 studies, 496 participants; I2 = 0%; high-certainty evidence). There was no clear effect on risk of pulmonary embolism (PE) (RR 0.81, 95% CI 0.18 to 3.59; 4 studies, 480 participants; I2 = 0%; low-certainty evidence). There was little to no difference in major bleeding with anticoagulation compared to placebo (RR 0.76, 95% CI 0.13 to 4.62; 4 studies, 480 participants; I2 = 26%; low-certainty evidence). There was an increase in clinically relevant non-major bleeding events in the group treated with anticoagulants (RR 3.34, 95% CI 1.07 to 10.46; 2 studies, 322 participants; I2 = 0%; high-certainty evidence). There was one death, not related to PE or major bleeding, in the anticoagulation group. Anticoagulation for three months or more compared to anticoagulation for six weeks for distal DVT treatment Three RCTs of 736 participants compared three or more months of anticoagulation with six weeks of anticoagulation. Anticoagulation with a VKA for three months or more reduced the incidence of recurrent VTE to 5.8% compared with 13.9% in participants treated for six weeks (RR 0.42, 95% CI 0.26 to 0.68; 3 studies, 736 participants; I2 = 50%; high-certainty evidence). The risk for recurrence of DVT was also reduced (RR 0.32, 95% CI 0.16 to 0.64; 2 studies, 389 participants; I2 = 48%; high-certainty evidence), but there was probably little or no difference in PE (RR 1.05, 95% CI 0.19 to 5.88; 2 studies, 389 participants; I2 = 0%; low-certainty evidence). There was no clear difference in major bleeding events (RR 3.42, 95% CI 0.36 to 32.35; 2 studies, 389 participants; I2 = 0%; low-certainty evidence) or clinically relevant non-major bleeding events (RR 1.76, 95% CI 0.90 to 3.42; 2 studies, 389 participants; I2 = 1%; low-certainty evidence) between three months or more of treatment and six weeks of treatment. There were no reports for overall mortality or PE and major bleeding-related deaths. AUTHORS' CONCLUSIONS Our review found a benefit for people with distal DVT treated with anticoagulation therapy using VKA with little or no difference in major bleeding events although there was an increase in clinically relevant non-major bleeding when compared to no intervention or placebo. The small number of participants in this meta-analysis and strength of evidence prompts a call for more research regarding the treatment of distal DVT. RCTs comparing different treatments and different treatment periods with placebo or compression therapy, are required.
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Affiliation(s)
- George Kirkilesis
- University of Patras Medical SchoolDepartment of Vascular SurgeryHippocrates Ave, RioPatrasAchaiaGreece26504
| | - Stavros K Kakkos
- University of Patras Medical SchoolDepartment of Vascular SurgeryHippocrates Ave, RioPatrasAchaiaGreece26504
| | - Colin Bicknell
- Imperial College LondonDepartment of Vascular SurgeryLondonUK
| | - Safa Salim
- Imperial College Healthcare NHS TrustTransplant DepartmentLondonUK
| | - Kyriaki Kakavia
- National and Kapodistrian University of AthensDepartment of Surgery, Laiko HospitalAthensGreece
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12
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Asonitis K, Charvalos E, Lambert C, Hermans C. Experience of a 40-day (6 week) LMWH treatment for isolated distal deep vein thrombosis. J Thromb Thrombolysis 2020; 50:837-843. [PMID: 32189191 DOI: 10.1007/s11239-020-02089-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Clinical significance of distal deep vein thrombosis (DVT) is important as it can potentially result in pulmonary embolism (PE), DVT extension, DVT recurrence and post-thrombotic syndrome (PTS). Controversy remains about the necessity and modalities of anticoagulation in all distal DVT. Evaluation of the efficiency of a 40-day weight-based low molecular weight heparin (LMWH) treatment in a cohort of 119 consecutive patients with distal DVT. Compression ultrasonography of the lower limb was performed initially for diagnosis as well as at the end of the treatment to identify persistence or resolution of the blood clot. A 3-month follow-up estimated the rates of PE, DVT recurrence, DVT extension, PTS and bleeding. Risk factors for DVT were considered to evaluate a possible correlation between them and the outcomes. In 71.4% of the patients the blood clot was totally dissolved and thrombus persistence was statistically associated with the number of initially involved veins. DVT recurrence occurred in 5% of patients and was also associated with the number of initial clotted veins. DVT extension and PTS rates were present in 1.7% and 3.4% respectively and no patient was diagnosed with PE or bleeding. This retrospective study including a limited number of patients and no control group supports that a 40-day weight-based LMWH treatment after distal DVT seems to be efficient when one single vein is initially affected whereas for multiple vein distal DVT and to avoid potential DVT recurrence, longer than 6 weeks of anticoagulant treatment is required. Our results support safety of the treatment, its potential to prevent DVT extension and the occurrence of PE.
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Affiliation(s)
- Konstantinos Asonitis
- Division of Haematology, Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc (UCL), Université Catholique de Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium.
| | | | - Catherine Lambert
- Division of Haematology, Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc (UCL), Université Catholique de Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | - Cedric Hermans
- Division of Haematology, Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc (UCL), Université Catholique de Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium
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13
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Quéré I, Galanaud JP, Sanchez O. [What is the management of sub-popliteal deep venous thrombosis?]. Rev Mal Respir 2019; 38 Suppl 1:e164-e170. [PMID: 31611025 DOI: 10.1016/j.rmr.2019.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- I Quéré
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Département de médecine vasculaire, centre de référence des maladies vasculaires rares, EA2992, université de Montpellier, CHU Montpellier, hôpital Saint-Éloi, 34295 Montpellier cedex 5, France
| | - J P Galanaud
- Département de médecine vasculaire, centre de référence des maladies vasculaires rares, EA2992, université de Montpellier, CHU Montpellier, hôpital Saint-Éloi, 34295 Montpellier cedex 5, France; Department of medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - O Sanchez
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Inserm UMRS 1140, service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, Assistance publique des Hôpitaux de Paris, université Paris Descartes, Sorbonne Paris cité, 75015 Paris, France; Service de pneumologie et soins intensifs, université de Paris, AH-HP, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
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14
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Quéré I, Elias A, Maufus M, Elias M, Sevestre MA, Galanaud JP, Bosson JL, Bura-Rivière A, Jurus C, Lacroix P, Zuily S, Diard A, Wahl D, Bertoletti L, Brisot D, Frappe P, Gillet JL, Ouvry P, Pernod G. [Unresolved questions on venous thromboembolic disease. Consensus statement of the French Society for Vascular Medicine (SFMV)]. JOURNAL DE MÉDECINE VASCULAIRE 2019; 44:e1-e47. [PMID: 30770089 DOI: 10.1016/j.jdmv.2018.12.178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- I Quéré
- Service de médecine vasculaire, CHU Montpellier, 80, avenue Augustun-Fliche, 34090 Montpellier, France
| | - A Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M Maufus
- Service de médecine vasculaire, CH Pierre Oudot, 38300 Bourgoin-Jallieu, France
| | - M Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M-A Sevestre
- Service de médecine vasculaire, CHU Amiens-Picardie, Avenue Laennec, 80054 Amiens cedex 1, France
| | - J-P Galanaud
- Département de médecine, Sunnybrook Health Sciences Centre, université de Toronto, Toronto, Canada
| | - J-L Bosson
- Département de biostatistiques, CHU Grenoble-Alpes, 38043 Grenoble, France
| | - A Bura-Rivière
- Service de médecine vasculaire, CHU Rangueil, 31059 Toulouse cedex 9, France
| | - C Jurus
- Service de médecine vasculaire, clinique du Tonkin, 69100 Villeurbanne, France
| | - P Lacroix
- Service de médecine vasculaire, Hôpital Dupuytren, CHU Limoges, 87042 Limoges cedex, France
| | - S Zuily
- Service de médecine vasculaire, Hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-Les-Nancy cedex, France
| | - A Diard
- Médecine vasculaire, 25, route de Créon, 33550 Langoiran, France
| | - D Wahl
- Service de médecine vasculaire, Hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-Les-Nancy cedex, France
| | - L Bertoletti
- Service de médecine vasculaire et thérapeutique, Hôpital Nord, CHU St-Étienne, 42, avenue Albert Raimond, 42270 Saint-Priest-en-Jarez, France
| | - D Brisot
- Médecine vasculaire, 34830 Clapiers, France
| | - P Frappe
- Département de médecine générale, université Jean-Monnet, 42000 St-Étienne, France
| | - J-L Gillet
- Médecine vasculaire, 38300 Bourgoin-Jallieu, France
| | - P Ouvry
- Médecine vasculaire, 1328, avenue de la Maison Blanche, 76550 Saint-Aubin-sur-Scie, France
| | - G Pernod
- Service de médecine vasculaire, CHU Grenoble-Alpes, 38043 Grenoble, France.
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15
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Quéré I, Elias A, Maufus M, Elias M, Sevestre MA, Galanaud JP, Bosson JL, Bura-Rivière A, Jurus C, Lacroix P, Zuily S, Diard A, Wahl D, Bertoletti L, Brisot D, Frappe P, Gillet JL, Ouvry P, Pernod G. Unresolved questions on venous thromboembolic disease. Consensus statement of the French Society for Vascular Medicine (SFMV). JOURNAL DE MEDECINE VASCULAIRE 2019; 44:28-70. [PMID: 30770082 DOI: 10.1016/j.jdmv.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/01/2018] [Indexed: 06/09/2023]
Affiliation(s)
- I Quéré
- Service de médecine vasculaire, CHU Montpellier, 80, avenue Augustun-Fliche, 34090 Montpellier, France
| | - A Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M Maufus
- Service de médecine vasculaire, CH Pierre Oudot, 38300 Bourgoin-Jallieu, France
| | - M Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M-A Sevestre
- Service de médecine vasculaire, CHU Amiens Picardie, avenue Laennec, 80054 Amiens cedex 1, France
| | - J-P Galanaud
- Département de médecine, Sunnybrook Health Sciences Centre, université de Toronto, Toronto, Canada
| | - J-L Bosson
- Département de biostatistiques, CHU Grenoble-Alpes, 38700 La Tronche, France
| | - A Bura-Rivière
- Service de médecine vasculaire, CHU Rangueil, 31059 Toulouse cedex 9, France
| | - C Jurus
- Service de médecine vasculaire, clinique du Tonkin, 69100 Villeurbanne, France
| | - P Lacroix
- Service de médecine vasculaire, hôpital Dupuytren, CHU Limoges, 87042 Limoges cedex, France
| | - S Zuily
- Service de médecine vasculaire, hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-les-Nancy cedex, France
| | - A Diard
- Médecine vasculaire, 25, route de Créon, 33550 Langoiran, France
| | - D Wahl
- Service de médecine vasculaire, hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-les-Nancy cedex, France
| | - L Bertoletti
- Service de médecine vasculaire et thérapeutique, hôpital Nord, CHU St.-Étienne, 42, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France
| | - D Brisot
- Médecine vasculaire, 34830 Clapiers, France
| | - P Frappe
- Département de médecine générale, université Jean-Monnet, 42000 St.-Étienne, France
| | - J-L Gillet
- Médecine vasculaire, 1328, avenue Maison-Blanche, 38300 Bourgoin-Jallieu, France
| | - P Ouvry
- Médecine vasculaire, 1328, avenue Maison-Blanche, 76550 Saint-Aubin-sur-Scie, France
| | - G Pernod
- Service de médecine vasculaire, CHU Grenoble-Alpes, avenue Maquis-du-Grésivaudan, 38043 Grenoble, France.
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16
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Salazar Adum JP, Golemi I, Paz LH, Diaz Quintero L, Tafur AJ, Caprini JA. Venous thromboembolism controversies. Dis Mon 2018; 64:408-444. [PMID: 29631864 DOI: 10.1016/j.disamonth.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | - Iva Golemi
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Luis H Paz
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Luis Diaz Quintero
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Alfonso J Tafur
- Cardiovascular Section, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201.
| | - Joseph A Caprini
- The University of Chicago Pritzker School of Medicine, Chicago, IL
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17
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Donadini MP, Dentali F, Pegoraro S, Pomero F, Brignone C, Guasti L, Steidl L, Ageno W. Long-term recurrence of venous thromboembolism after short-term treatment of symptomatic isolated distal deep vein thrombosis: A cohort study. Vasc Med 2017; 22:518-524. [DOI: 10.1177/1358863x17720531] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Isolated distal deep vein thrombosis (IDDVT) is a common clinical manifestation of venous thromboembolism (VTE). However, there are only scant and heterogeneous data available on the long-term risk of recurrent VTE after IDDVT, and the optimal therapeutic management remains uncertain. We carried out a retrospective cohort study of consecutive patients diagnosed with symptomatic IDDVT between 2004 and 2011, according to a predefined short-term treatment protocol (low molecular weight heparin (LMWH) for 4–6 weeks). The primary outcome was the occurrence of recurrent VTE. A total of 321 patients were enrolled. IDDVT was associated with a transient risk factor or cancer in 165 (51.4%) and 56 (17.4%) patients, respectively. LMWH was administered for 4–6 weeks to 280 patients (87.2%), who were included in the primary analysis. Overall, during a mean follow-up of 42.3 months, 42 patients (15%) developed recurrent VTE, which occurred as proximal DVT or PE in 21 cases. The recurrence rate of VTE per 100 patient-years was 3.5 in patients with transient risk factors, 7.2 in patients with unprovoked IDDVT, and 5.9 in patients with cancer ( p=0.018). At multivariable analysis, unprovoked IDDVT and previous VTE were significantly associated with recurrent VTE (HR 2.16, 95% CI 1.12–4.16 and HR 1.97, 95% CI 1.01–3.86, respectively). In conclusion, the long-term risk of recurrent VTE after IDDVT treated for 4–6 weeks is not negligible, in particular in patients with unprovoked IDDVT or cancer. Further studies are needed to clarify whether a longer, but definite treatment duration effectively prevents these recurrences.
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Affiliation(s)
- Marco P Donadini
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Samuela Pegoraro
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Fulvio Pomero
- Department of Internal Medicine, Ospedale ‘S. Croce e Carle’, Cuneo, Italy
| | - Chiara Brignone
- Department of Internal Medicine, Ospedale ‘S. Croce e Carle’, Cuneo, Italy
| | - Luigina Guasti
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Luigi Steidl
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
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18
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Franco L, Giustozzi M, Agnelli G, Becattini C. Anticoagulation in patients with isolated distal deep vein thrombosis: a meta-analysis. J Thromb Haemost 2017; 15:1142-1154. [PMID: 28316124 DOI: 10.1111/jth.13677] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Indexed: 11/27/2022]
Abstract
Essentials The optimal management of isolated distal deep vein thrombosis (IDDVT) is undefined. This meta-analysis aimed to assess the clinical benefit of anticoagulation for IDDVT. Anticoagulation reduced the rate of pulmonary embolism without increasing major bleeding risk. Recurrent thromboembolism was less common with more than 6 weeks vs. 6 weeks of anticoagulation. SUMMARY Background The optimal management of patients with isolated distal deep vein thrombosis (IDDVT), concerning both the need for anticoagulation and its duration, is undefined. Objectives We performed a meta-analysis of randomized and cohort studies in patients with IDDVT to assess the clinical benefit of: (i) anticoagulation versus no anticoagulation; and (ii) anticoagulant treatment for 6 weeks versus for > 6 weeks. Methods The primary outcome of this analysis was recurrent venous thromboembolism (proximal propagation, recurrence of deep vein thrombosis, and pulmonary embolism). Data were pooled and compared by the use of odds ratio (OR) and 95% confidence interval (CI). Results A reduction in the rate of recurrent venous thromboembolism was observed in patients who received anticoagulation relative to those who did not receive anticoagulation (either therapeutic or prophylactic) (20 studies, 2936 patients; OR 0.50, 95% CI 0.31-0.79), without an increase in the risk of major bleeding (OR 0.64, 95% CI 0.15-2.73). The rate of pulmonary embolism was lower in anticoagulant-treated patients than in controls (15 studies, 1997 patients; OR 0.48, 95% CI 0.25-0.91). A lower rate of recurrent venous thromboembolism was observed in patients who received > 6 weeks of anticoagulant therapy than in those who received 6 weeks of anticoagulant therapy (four studies, 1136 patients; OR 0.39, 95% CI 0.17-0.90). Conclusions In patients with IDDVT, anticoagulation (both therapeutic and prophylactic) reduces the rate of recurrent venous thromboembolism and the incidence of pulmonary embolism as compared with no anticoagulation, without an increased risk of major bleeding. Anticoagulation for > 6 weeks should be preferred over shorter durations.
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Affiliation(s)
- L Franco
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - M Giustozzi
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - G Agnelli
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - C Becattini
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
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19
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Abstract
The natural history of isolated distal deep-vein thrombosis (IDDVT) is still uncertain, as well as the real clinical risks associated with the disease and the need for its diagnosis and treatment. While more and more IDDVTs are diagnosed in everyday clinical practice, their appropriate therapeutic management is, unfortunately, far from straightforward, and different recommendations on how patients with diagnosed IDDVT should be treated are present between expert professionals and even among international guidelines. The present article aims at briefly reviewing the issue of IDDVT therapy in general, particularly focusing on the different approaches to the treatment of the disease that have been suggested by recent guidelines, those that are currently adopted in clinical practice, and necessary future directions.
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Affiliation(s)
- Gualtiero Palareti
- Cardiovascular Diseases, University of Bologna, Bologna, Italy.
- Arianna Anticoagulation Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy.
| | - Michelangelo Sartori
- Unit of Angiology and Blood Coagulation, University Hospital of Bologna, Bologna, Italy
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20
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Batur A, Polat V, Ozgokce M, Alpaslan M, Yavuz A, Arslan H, Bora A, Sakarya ME. Pulsatility Index of Popliteal Artery in Patients with Isolated Calf Vein Thrombosis: A Novel Technique for Detecting Thrombosis. Pol J Radiol 2017; 82:161-164. [PMID: 28392853 PMCID: PMC5375175 DOI: 10.12659/pjr.899949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/09/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To investigate the usefulness of popliteal artery spectral doppler findings as a complimentary approach to isolated calf vein thrombosis (DVT). MATERIAL/METHODS We included consecutive patients presenting with symptomatic and sonographically proven acute isolated calf DVT. Patients with thrombosis of any other vein were excluded. We classified calf vein into into four main types. We investigated how many of these four vessels had DVT and compared them with respect to the pulsatility index (PI) value of the popliteal artery. RESULTS We evaluated spectral doppler characteristics of the popliteal artery on the same side as the isolated calf vein thrombosis as well as on the opposite side. The relationship between PI values of the popliteal artery and the number of thrombosed calf veins was investigated. In patients with 1 and/or 2 thrombosed veins, the mean PI was 6.03±0.54 on the side of cDVT and 5.68±0.39 on the opposite side (p=0.008), respectively. Inpatients with 3 and/or 4 thrombosed veins, the mean PI was 8.05±0.61 on the side of cDVT and 6.34±0.47 on the opposite side (p=0.001), respectively. CONCLUSIONS Venous doppler sonography for the evaluation of calf DVT may be limited by patient characteristics such as obesity, edema, and tenderness., Arterial PI can be used as a complimentary technique for the detection of venous thrombosis in such of cases.
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Affiliation(s)
- Abdussamet Batur
- Department of Radiology, Yuzuncuyil University, Dursun Odabas Medical Center, Van, Turkey
| | - Vural Polat
- Department of Cardiovascular Surgery, Yuzuncuyil University, Dursun Odabas Medical Center, Van, Turkey
| | - Mesut Ozgokce
- Department of Radiology, Yuzuncuyil University, Dursun Odabas Medical Center, Van, Turkey
| | - Muhammed Alpaslan
- Department of Radiology, Yuzuncuyil University, Dursun Odabas Medical Center, Van, Turkey
| | - Alpaslan Yavuz
- Department of Radiology, Yuzuncuyil University, Dursun Odabas Medical Center, Van, Turkey
| | - Harun Arslan
- Department of Radiology, Yuzuncuyil University, Dursun Odabas Medical Center, Van, Turkey
| | - Aydin Bora
- Department of Radiology, Yuzuncuyil University, Dursun Odabas Medical Center, Van, Turkey
| | - Mehmet Emin Sakarya
- Department of Radiology, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
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Wu AR, Garry J, Labropoulos N. Incidence of pulmonary embolism in patients with isolated calf deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2016; 5:274-279. [PMID: 28214497 DOI: 10.1016/j.jvsv.2016.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/24/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The severity of pulmonary embolism (PE) after isolated calf deep vein thrombosis (C-DVT) is controversial, which leads to inconsistent clinical decision making when treating C-DVT. This systematic review assessed PE frequency and severity in patients with C-DVT. METHODS Database searches were completed using MEDLINE and Scopus along with cross-referencing. Two independent reviewers used using rigorous inclusion and exclusion criteria to screen the papers. Data concerning PE and C-DVT characteristics as well as methods of detection were abstracted. Studies reporting combined outcomes for patients with proximal and C-DVT, those with concurrent PE at diagnosis, and retrospective studies not allowing the determination of C-DVT and PE as separate events were excluded. RESULTS Of 586 papers that were screened, 21 met inclusion criteria, which included eight randomized clinical trials and 13 prospective cohort studies. There was data heterogeneity among patients, methods of diagnosis, and follow-up. PE diagnosis was often based on ventilation/perfusion scanning, where more recent studies used computed tomography angiography. The PE is usually overestimated because it includes concurrent events. The incidence of PE from isolated C-DVT in our review was 0% to 6.2%. No fatal PEs were reported. No data were found on PE severity and patient outcomes regarding this complication. CONCLUSIONS Reported adverse outcomes of PE from C-DVT are infrequent, and clinical severity is unclear. Further studies are necessary to determine the actual risk associated with PE after C-DVT to establish proper treatment.
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Affiliation(s)
- Alvin R Wu
- Division of Vascular Surgery, Stony Brook School of Medicine, Stony Brook, NY
| | - Jonah Garry
- Division of Vascular Surgery, Stony Brook School of Medicine, Stony Brook, NY
| | - Nicos Labropoulos
- Division of Vascular Surgery, Stony Brook School of Medicine, Stony Brook, NY.
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22
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Garry J, Duke A, Labropoulos N. Systematic review of the complications following isolated calf deep vein thrombosis. Br J Surg 2016; 103:789-96. [DOI: 10.1002/bjs.10152] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/03/2015] [Accepted: 02/10/2016] [Indexed: 01/23/2023]
Abstract
Abstract
Background
A large number of studies have examined the potential complications of calf deep vein thrombosis (DVT). There is no consensus on when or how to treat patients to prevent these complications. This systematic review assessed the rate of proximal propagation, pulmonary embolism, major bleeding and recurrence in patients with isolated calf DVT.
Methods
Database searches of MEDLINE, the Cochrane Library, Scopus, CINAHL and Web of Science were undertaken along with extensive cross-referencing. Two independent reviewers screened the papers using stringent inclusion and exclusion criteria. Included studies were graded on six methodological standards. Data on propagation, pulmonary embolism, recurrence and major bleeding were abstracted.
Results
A total of 4261 papers were found; 15 met the inclusion criteria, including five randomized clinical trials and ten prospective cohort studies. The propagation rate to the popliteal vein or above was around 9 per cent and the rate of pulmonary embolism was close to 1·5 per cent. No studies found anticoagulant therapy to reduce the rate of adverse outcomes.
Conclusion
The literature on calf DVT is heterogeneous, limiting conclusions from data analysis. Adverse outcomes are infrequent and studies do not suggest that they are reduced by anticoagulation.
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Affiliation(s)
- J Garry
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - A Duke
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - N Labropoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York, USA
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23
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Brahmandam AS, Brownson K, Skrip L, Parker T, Indes J, Sarac T, Dardik A, Chaar CIO. Management of isolated calf vein thrombosis in cancer patients. Vascular 2015; 24:64-9. [PMID: 25957344 DOI: 10.1177/1708538115584726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The treatment of isolated calf vein thrombosis remains widely debated. This study highlights the characteristics of isolated calf vein thrombosis in cancer patients and compares to isolated calf vein thrombosis in patients without history of cancer. Between July 2013 and April 2014, a retrospective chart review of consecutive patients with isolated calf vein thrombosis was performed recording patient risk factors, ultrasound characteristics of the thrombus, treatment modalities, long-term recurrence of venous-thromboembolism, incidence of bleeding, and mortality. Of 131 patients with isolated calf vein thrombosis, 53 (40.1%) had history of cancer. Isolated calf vein thrombosis occurred at an older age in cancer patients (66.7 vs 58.5 years, p = 0.004). The anatomical characteristics of isolated calf vein thrombosis on ultrasound were comparable in both groups. Isolated calf vein thrombosis in cancer patients was less likely to be treated with anticoagulation (60.4% vs 80.8%, p = 0.018). However, a trend towards higher incidence of bleeding after initiation of anticoagulation for isolated calf vein thrombosis in cancer patients (11.3% vs 6.4%, p = 0.351) was noted. Mortality in cancer patients was higher (37.7% vs 9.00%, p < 0.001) but was unrelated to isolated calf vein thrombosis or its treatment. In conclusion, the risks of bleeding seem to exceed the benefits of anticoagulation in approximately 50% of cancer patients with isolated calf vein thrombosis. The management of isolated calf vein thrombosis does not seem to impact the survival of cancer patients.
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Affiliation(s)
- Anand S Brahmandam
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Kirstyn Brownson
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Laura Skrip
- Department of Epidemiology and Microbial Diseases, Yale University School of Public Health, New Haven, CT, USA
| | - Terri Parker
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey Indes
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Timur Sarac
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alan Dardik
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Cassius Iyad Ochoa Chaar
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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Li AY, Woulfe T, Rolfe-Vyson V, Rowland V, Simpson D, Merriman E. Management and outcomes of axial isolated distal deep vein thrombosis at North Shore Hospital, New Zealand: a retrospective audit. Intern Med J 2015; 45:177-82. [DOI: 10.1111/imj.12664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 11/20/2014] [Indexed: 12/01/2022]
Affiliation(s)
- A. Y. Li
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - T. Woulfe
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - V. Rolfe-Vyson
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - V. Rowland
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - D. Simpson
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - E. Merriman
- Haematology Department; North Shore Hospital; Auckland New Zealand
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Middeldorp S, Prins MH, Hutten BA. Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism. Cochrane Database Syst Rev 2014; 2014:CD001367. [PMID: 25092359 PMCID: PMC7074008 DOI: 10.1002/14651858.cd001367.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Currently, the most frequently used secondary treatment for patients with venous thromboembolism (VTE) consists of vitamin K antagonists (VKA) targeted at an international normalized ratio (INR) of 2.5 (range 2.0 to 3.0). However, based on the continuing risk of bleeding and uncertainty regarding the risk of recurrent VTE, discussion on the proper duration of treatment with VKA for these patients is ongoing. Several studies have compared the risks and benefits of different durations of VKA in patients with VTE. This is the third update of a review first published in 2000. OBJECTIVES To evaluate the efficacy and safety of different durations of treatment with vitamin K antagonists in patients with symptomatic venous thromboembolism. SEARCH METHODS For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 9. SELECTION CRITERIA Randomized controlled clinical trials comparing different durations of treatment with vitamin K antagonists in patients with symptomatic venous thromboembolism. DATA COLLECTION AND ANALYSIS Three review authors (SM, MP, and BH) extracted the data and assessed the quality of the trials independently. MAIN RESULTS Eleven studies with a total of 3716 participants were included. A consistent and strong reduction in the risk of recurrent venous thromboembolic events was observed during prolonged treatment with VKA (risk ratio (RR) 0.20, 95% confidence interval (CI) 0.11 to 0.38) independent of the period elapsed since the index thrombotic event. A statistically significant "rebound" phenomenon (ie, an excess of recurrences shortly after cessation of prolonged treatment) was not found (RR 1.28, 95% CI 0.97 to 1.70). In addition, a substantial increase in bleeding complications was observed for patients receiving prolonged treatment during the entire period after randomization (RR 2.60, 95% CI 1.51 to 4.49). No reduction in mortality was noted during the entire study period (RR 0.89, 95% CI 0.66 to 1.21, P = 0.46). AUTHORS' CONCLUSIONS In conclusion, this review shows that treatment with VKA strongly reduces the risk of recurrent VTE for as long as they are used. However, the absolute risk of recurrent VTE declines over time, although the risk for major bleeding remains. Thus, the efficacy of VKA administration decreases over time since the index event.
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Affiliation(s)
- Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Martin H Prins
- CAPHRI Research School, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands6200 MD
| | - Barbara A Hutten
- Academic Medical CenterDepartment of Clinical Epidemiology & BiostatisticsMeibergdreef 9AmsterdamNetherlands1105 AZ
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Henry JC, Satiani B. Calf muscle venous thrombosis: a review of the clinical implications and therapy. Vasc Endovascular Surg 2014; 48:396-401. [PMID: 25027613 DOI: 10.1177/1538574414541704] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Calf muscle veins have been demonstrated to be one of the most frequent areas that develop deep venous thrombosis (DVT), both as an isolated finding and in combination with proximal DVT. Calf muscle venous thrombosis (CMVT) has been shown to be more frequently associated with localized calf tenderness, and when left untreated, a proportion tend to propagate proximally and may lead to pulmonary embolism. Imaging with duplex venous scanning is fairly sensitive in the diagnosis of CMVT. Treatment recommendations for CMVT are variable with some studies showing clear clinical benefit of anticoagulation therapy and others showing no benefit.
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Affiliation(s)
- Jon C Henry
- Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Bhagwan Satiani
- Division of Vascular Diseases and Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
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Galanaud JP, Sevestre MA, Genty C, Kahn SR, Pernod G, Rolland C, Diard A, Dupas S, Jurus C, Diamand JM, Quere I, Bosson JL. Incidence and predictors of venous thromboembolism recurrence after a first isolated distal deep vein thrombosis. J Thromb Haemost 2014; 12:436-43. [PMID: 24450376 DOI: 10.1111/jth.12512] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 01/16/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Isolated distal deep vein thrombosis (iDDVT) (i.e. without proximal DVT or pulmonary embolism) represents half of all cases of lower limb DVT. Its clinical significance and management are controversial. Data on long-term follow-up are scarce, especially concerning risk and predictors of venous thromboembolism (VTE) recurrence. METHODS Using data from the OPTIMEV (OPTimisation de l'Interrogatoire dans l'évaluation du risque throMbo-Embolique Veineux) study, a prospective, observational, multicenter study, we compared, 3 years after an index VTE event and after discontinuation of anticoagulants, (i) the incidence and type of recurrence in patients without cancer with a first iDDVT vs. a first isolated proximal DVT (iPDVT) and (ii) predictors of recurrence after iDDVT. RESULTS Compared with patients with iPDVT (n = 259), patients with an iDDVT (n = 490) had a lower annualized incidence of overall VTE recurrence (5.2% [95% confidence interval 3.6-7.6] vs. 2.7% [1.9-3.8], respectively; P = 0.02) but a similar incidence of pulmonary embolism recurrence (1.0% [0.5-2.3] vs. 0.9% [0.5-1.6], respectively; P = 0.83). An age of > 50 years, unprovoked character of index iDDVT, and involvement of more than one vein in one or both legs each independently tripled the risk of recurrence, with the latter then being ≥ 3% per patient-year. Neither muscular vein nor deep-calf vein location of iDDVT nor clot diameter with compression influenced the risk of recurrence. CONCLUSIONS After stopping anticoagulants, patients with iDDVT have a significantly lower risk of overall VTE recurrence than did patients with iPDVT but a similar risk of serious recurrent VTE. Age > 50 years, unprovoked iDDVT, and number of thrombosed veins (more than one) influenced the risk of recurrence and may help to define patients at significant risk of recurrence.
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Affiliation(s)
- J-P Galanaud
- Clinical Investigation Center and Department of Internal Medicine, Montpellier University Hospital, Montpellier, France
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Masuda EM, Kistner RL, Musikasinthorn C, Liquido F, Geling O, He Q. The controversy of managing calf vein thrombosis. J Vasc Surg 2012; 55:550-61. [DOI: 10.1016/j.jvs.2011.05.092] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 05/31/2011] [Accepted: 05/31/2011] [Indexed: 11/26/2022]
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Abstract
Thromboses that are restricted to the infra-popliteal deep veins of the lower limbs (isolated distal deep vein thrombosis, IDDVT) are frequently diagnosed in subjects with suspected pulmonary embolism (PE; 7–10%) or DVT(4–15%), accounting for 31–56% of all diagnosed leg DVTs. Despite their frequency, IDDVTs still remain one of the most debated issues in the field of venous thromboembolism (VTE). Conflicting clinical results have resulted in differing opinions on the need to test for IDDVTs and how to treat them. Due to discordant results, the real risk of IDDVT-associated PE is not well established. IDDVTs are associated with (i) lower risk of recurrence when compared with other VTEs, and (ii) fewer late sequelae than proximal DVT. Diagnosis of IDDVT is based on ultrasound examination of all calf veins, which is more operator-dependent and less sensitive than proximal vein examination. A series of studies has shown, however, that a single complete ultrasound strategy in symptomatic patients has comparable clinical results to serial proximal ultrasound, allowing approximately 15% better DVT diagnosis. Optimal treatment of IDDVT is still controversial. Guidelines recommend anticoagulation for 12 weeks, although 6 weeks may be sufficient. There is, however, insufficient data to support the diagnosis and treatment of all IDDVTs, and the necessary criteria to identify subjects at higher risk of complication are lacking. It also seems likely that different approaches may be better for unprovoked or secondary events and for deep or muscle veins. Specifically designed and adequately powered clinical studies addressing the issue of IDDVT need to be urgently undertaken.
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Affiliation(s)
- Gualtiero Palareti
- Department of Angiology and Blood Coagulation, University Hospital of Bologna, Italy.
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30
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The case for managing calf vein thrombi with duplex surveillance and selective anticoagulation. Dis Mon 2010; 56:601-13. [PMID: 20971331 DOI: 10.1016/j.disamonth.2010.06.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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